Could involving patients decrease antibiotic prescriptions?

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When patients and doctors share in decisions about antibiotics for respiratory infections, fewer antibiotics are prescribed - and that's a good thing, according to researchers who reviewed the subject.

Over-prescription of antibiotics for conditions that do not require them exposes more bacteria to the drugs and speeds resistant mutations - making the drugs less effective when they are actually needed.

A recent World Health Organization survey found that more than half of people surveyed believed, incorrectly, that antibiotics could treat cold and flu.

Doctors may feel that patients 'want' antibiotics - or they may be in the habit of prescribing them, even when they are not warranted, said Tammy C. Hoffmann of the Center for Research in Evidence-Based Practice (CREBP) at Bond University in Australia, senior author of the new review.

Primary care doctors may be less likely to see the negative effects of antibiotic resistance, because most of the 25,000 American deaths last year from antibiotic resistance occurred in hospitals, not in primary care offices, Hoffmann said.

According to her team's new review of past research, when patients and doctors discuss antibiotic prescribing together, fewer drugs are given out.

"What is good is that this is one of the first reviews of shared decision making interventions that demonstrates a good clinical outcome (decreased antibiotic use without damage to patient satisfaction)," Hoffman told Reuters Health by email.

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The new review included 10 randomized controlled trials involving more than 1,000 primary care doctors and hundreds of thousands of patients in the U.K. and Europe. The trials tested interventions to encourage collaboration between doctors and patients on antibiotic prescribing decisions.

Some involved training doctors in specific communication skills to establish patients' concerns and beliefs about the need for antibiotics, their harms and benefits, and to agree on a management plan. Others also included giving written information about antibiotics to patients, and encouraging discussion with doctors about whether they are necessary.

Within six weeks of these consultations, antibiotic prescriptions for acute respiratory infections were lower in the training and education groups than in comparison groups that had received no intervention.

In eight of the trials, almost half of patients in the comparison groups were given an antibiotic prescription, compared to 29 percent in the shared decision-making groups.

Longer-term effects were unclear, the researchers report in their results in the Cochrane Library.

"Shared decision-making means that the options are discussed; the natural course of the illness is discussed (i.e., these infections usually get better by themselves, so the option of not taking antibiotics is certainly one option that is reasonable to consider and discuss)," Hoffman said.

In these discussions, patients can weigh the marginal amount of benefit that is often provided by antibiotics in common acute respiratory infections against the risk of harm, she said.

"Not all patients will want to be involved in collaborative decision making with their clinician and that is fine if that is their choice - but they should be at least offered the opportunity," Hoffman said. "It shouldn't be used as a way of convincing a patient to do, or not do, something."

Dr. Ralph Gonzales of UCSF School of Medicine, who studies antibiotic prescribing practices, told Reuters Health, "My one reaction to shared decision making around this topic is that the decision to use a medication that has public health implications because of how it provides antimicrobial resistance is not necessarily one that is ideal for shared decision making."

Involving patients in treatment decisions makes most sense when the benefits and harms primarily will affect the individual patient, such as deciding whether or not to screen for or treat certain slow-moving cancers in advanced age, Gonzales said in a phone interview.

The harms of antibiotic over-prescription affect the general public rather than the individual, he said.

"Patients should not be making decisions about treatments that have larger societal and public health implications, with no individual benefit," he said.

In theory, if a patient truly wants an antibiotic, even if it will not treat their respiratory infection, the doctor would prescribe it in a shared decision-making situation, which would go against the evidence, Gonzales said.